Civilization in the United States: An inquiry by thirty Americans

by Unknown

But at the present time this adorable figure is disappearing from the land, to be replaced by another, more sinister type, actually less learned in the important folklore of the bedside, pseudo-scientific, given to rigidly defined office hours, and painfully exact in the extortion of his emolument. What are the factors that give rise to the appearance of this new figure on the American scene? The most important of these is to be found in the high development of the craft of surgery in the United States. Of all the dread afflictions that plague us, a few may be cured or ameliorated by the administration of remedies, and an equally small number improved or abolished by surgical interference. But in spite of the relatively few diseases to which surgery is beneficial, the number of surgeons that flourish in the land is enormous. The fundamental discoveries of Pasteur and their brilliant application by Lister were quickly seized upon in America. The names of Bull, Halstead, Murphy, the brothers Mayo, Cushing, and Finney are to be ranked with those of the best surgeons of any nation. In fact, we may be said to lead the world—to use an apt Americanism—in the production of surgeons, just as we do in that of automobiles, baby carriages, and antique furniture.

The success of these protagonists in the higher carpentry at once attracted a horde of smaller fry, imitators, men of inferior ability. The rapid advances made by the leaders resulted in the development of a diversified and complicated technic, which the ordinary surgeon was able to master in sections but not in toto. From this, specialization in surgery has developed rapidly and naturally, so that now certain men devote their lives exclusively to the enthusiastic and indiscriminate removal of tonsils, others are death on gall bladders, some the foes of the vermiform appendix, and yet others practise exclusively the radical cure of phimosis. It is obvious that such narrow specialization, practised in isolation, would lead to most amusing results, which may best be left to the imagination. But these absurdities were finally apparent even to the surgeons themselves, with the resulting development of what is now known as “group medicine.”

In brief, surgeons with special penchants for the removal of various organs, form partnerships, calling to their aid the internist for the diagnosis of their prospective victims. The internist gathers about him, in turn, a group of less important fry, known as radiographers, bacteriologists, pathologists, and serologists. Frequently a dentist is added to the coterie. The entire organization is welded into a business partnership of typically American efficiency. These groups are forming over the entire nation, are appearing even in the tank-towns of the hinterland. They occupy elegant suites in important office buildings, their members are generally considered the arbiters of the medical opinion of the community. Their more or less intelligent use of the paraphernalia of pathology, bacteriology, et cetera, gives them an enormous advantage over their more humble brother, the general practitioner. This last, indeed, is being rapidly routed in his battle with such associations of “best minds,” equipped with the armamentarium of modern science.

The remuneration required by the “super-docs” of group medicine is naturally far in excess of that demanded by the general practitioner. It is right that this should be so, if not for the results obtained, then by reason of the elaborate organization and expensive equipment that the group system demands. This increase in reward has made the profession of medicine in America what it never was before, a paying proposition—again to use an apt Americanism. The result of this entry of crass materialism into a previously free-and-easy, altruistic, anything but business-like profession is, once more, better left to the imagination than described. The brigandage of many of these medical banditti is too painful even to think about. It will be apparent that relatively few of our citizens are able to pay for group medicine. So, it is interesting to observe that the best in medical treatment and advice is accessible only to the highest and lowest castes of our plutocracy. The rich receive this at the elegant offices and private hospitals of the groups, the miserably poor at the teaching hospitals of medical colleges.

The service of the “super-doc” to such of our citizens as can afford him cannot at this time be properly estimated. It is true that he is progressive, that he leans heavily upon the subsidiary sciences of pathology, et cetera, that he publishes papers in medical periodicals, that he visits medical libraries, frequents medical congresses. It has just been insisted that the doctor has benefitted himself to a great extent economically by forming the group; it is for the future to divulge whether his ministrations have resulted in a perceptible reduction of human suffering or in a prolongation of human life. Certainly he has perpetrated some astounding hoaxes, the kind-hearted will say unwittingly. Probably the most interesting of these is to be observed in the focal infection mania just now subsiding.

Focal infection came into prominence as the theory, so called, of a group of eminent physicians in Chicago. It is, in brief, the doctrine that many of our aches and pains whose direct etiology it is impossible to demonstrate are due to the presence in the body of foci of harmful microbes, at the roots of the teeth, in the tonsils, accessory sinuses, or the appendix. Discover the focus, remove it, and presto!—the ache disappears like the card up the sleeve of the expert American poker player. The advantages of this theory to the various specialists of a group will be obvious. To illustrate. Henry Doolittle is plagued by a persistent and annoying pain over his left shoulder-blade. He goes to the office of a group of “super-docs,” is referred to the diagnostician, who makes a careful record of his status præsens, then orders his satellites to perform the Wassermann reaction, make the luetin test, do differential blood counts, perform the determination of his blood urea, and carry out a thorough chemical study of his basal metabolism. If the results of these tests show no departure from the normal, or if they seriously contradict each other, the cause of the pain is probably focal infection. The patient is then subjected to examination by X-ray, his teeth are pulled by the dentist, his tonsils excised by the otolaryngolist, who also takes a swipe, in passing, at his accessory sinuses, and should these mutilations fail to relieve him, his appendix is removed by the abdominal surgeon. If relief still fails to occur, the theory is not given up, but the focus is presumed to exist elsewhere. If Mr. Doolittle’s patience is equal to the test, and if his purse is not by this time completely empty, additional operations are advised. These continue until all organs and appendages not actually necessary to mere existence have been removed. Henry then returns to his former mode of life, depleted and deformed, it is true, but occasionally minus his original pain. It is not the intention to deny that infected teeth and tonsils have no significance in pathology. But it is certain that their importance has been greatly exaggerated by many physicians. The question needs more investigation, with fewer preconceived ideas. The “science” underlying this astounding practice is admirably outlined in the book of Billings called “Focal Infection.” It is the most striking example of medical Ga-Ga-ism that has appeared in our country. It is, as its author himself admits, a triumph of the new idea of team-work and co-operative research in medicine. The factors giving rise to this lamentable Ga-Ga are the gullibility of patient and doctor, the emotional element entering into the interpretation of all of the phenomena observed by the physician, commercialism, and, finally, the self-limiting nature of most disease.

So much for the Art of Healing as practised by the physicians of America. What of our activities in the second aim of medicine, that is, the prevention of disease? While superficial examination is enough to lay bare the many hollow pretensions of the practice of medicine, it would appear a priori that the work of disease prevention might at least approach the category of the applied sciences. This would seem to be so, since the greater part of this field must of necessity concern itself with infectious disease. Now the etiologic agents of the majority of infectious diseases are known. It is easy to see that the labour of their prevention rests upon an exact knowledge of the nature of the disease-producing microbes, the analysis of the delicate balance between the virulence of the microbic invader and the resistance of the human host, and, most important of all, upon the exact path by which the germ in question travels from one individual to another.

In the early days of preventive medicine, following shortly upon the fundamental researches of Pasteur, several important contributions were made by Americans. These include the brilliant investigations of Theobald Smith on the etiology and mode of transmission of the Texas fever of cattle, and, later on, the differentiation of bovine and human tuberculosis. America had again reason to be proud when, in 1901, Reed, Carroll, Agramonte, and Lazear demonstrated that yellow fever was spread exclusively by the mosquito, Ædes calopus. These investigators showed a beautiful spirit of self-sacrifice and devotion to their science. The construction of the Panama Canal was made possible by the application of these researches by Gorgas. Again, the American Russell was the first to show that vaccination against typhoid and allied infections is feasible. In the New York Board of Health, Park, Krumwiede, and their associates have made careful and valuable studies on the prevention of diphtheria. These constitute the high lights of American achievement in preventive medicine. It must be admitted that the majority of these examples are to be placed in the category of the science of the study of disease, rather than in that of its application—preventive medicine.

It is noticeable even by cursory survey of recent American work that such striking achievements have become distinctly fewer in recent years, despite an enormous increase in personnel, equipment, and money devoted to the prevention of disease. Along with this decrease in solid contributions there has been an augmentation of fatuous propaganda and windy theory. All of the judicious must view this tendency with alarm and sadness, since it seemed for a time that science was really about to remove the vestigia of witchcraft and high-priesthood from this branch of medicine at least.

What is the cause of this retrogression? It must be laid at the door of Religio Sanitatis, the Crusade of Health. This is one of the most striking examples of the delusion of most Americans that they are the Heaven-appointed uplifters of the human race. Just as all Baptists, Presbyterians, and Methodists deprecate the heathen happiness of the benighted Oriental, so the International Health Board seeks to mitigate his contented squalour and to eradicate his fatalistically born disease. Just as Billy Sunday rages against John Barleycorn and the Dionysians who worship him, so the Great Hygienists seek to point out the multiform malaises arising from such worship. Just as the now extinct Wilson strove to show the world that it was horrid and wrong to fight, so the Public Health Service seeks to propagate the notion that chastity and adherence to marital vows are the sole alternatives to a universal syphilization.